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msJAMA
April 10, 2002

Declining Student Interest in Psychiatry

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JAMA. 2002;287(14):1859. doi:10.1001/jama.287.14.1859-JMS0410-5-1

After the number of US psychiatrists reached a zenith in the 1960s, there has been a consistent decrease in recruitment into the profession. During 1988-1998 alone, the number of medical students choosing to pursue a psychiatry residency fell by 42.5%, to a current rate of 3%. This significant decrease from the rates of 7% to 10% in the post–War World II years1 has occurred despite an unchanging prevalence of psychiatric disorders in the United States.2 Thus, it is important to understand medical students' current perceptions of the field of psychiatry.

Negative attitudes toward psychiatry often exist before students start medical school. In a 1999 study, first-year medical students rated psychiatry significantly lower than the 3 other specialties surveyed (surgery, internal medicine, and pediatrics) as a desirable career.3 Psychiatry was rated lowest in prestige, helpfulness to patients, intellectual challenge, and expectation of having a bright and interesting future. These negative attitudes appear to persist even after a clerkship experience.1 Fourth-year students who chose not to pursue a psychiatry residency cited low effectiveness of psychiatric treatments, poor opinions of peers and faculty about psychiatry, and lack of status of psychiatry within medicine as some of the factors in their decision. In addition, they appear less likely than those entering psychiatry residencies to view the field as intellectually challenging and professionally satisfying to residents.4 These results are especially significant since the clerkship experience is far more influential in students' decision to pursue psychiatry than it is in any other field.5 These surveys reveal that although some factors that discourage students from psychiatry are based on realities, others are based on misperceptions that persist despite clinical experiences in medical school.

Declining student interest in psychiatry has been partially attributed to perceptions of disparities in insurance coverage for mental health problems, which may limit psychiatrists' ability to provide care.1 Fourth-year medical students listed "health care reform and its impact on psychiatry" and the "impact of managed care trends on psychiatry" as factors that dissuade them from choosing a career in psychiatry.4 These disparities may be felt especially acutely by medical students, as psychiatry departments were the first to face cutbacks and reductions in inpatient care after the congressionally mandated Balanced Budget Act of 1997.6 A 1995 meta-analysis found that residency recruitment into psychiatry departments increased in direct proportion to resources devoted to psychiatric and mental health education.1 For example, two of the schools with the highest match rates into psychiatry were Michigan State University College of Human Medicine, with a 1:1 faculty-to-student ratio during clerkships, and Mayo Medical School, which had 28 full-time psychiatric faculty for 42 students per class.1

Although students' perceptions of financial disparities may reflect realistic concerns, their beliefs about the ineffectiveness of psychiatric treatments are often based on misperceptions. There is ample evidence that psychiatric treatments are just as effective, if not more so, than those for other illnesses.7 It is curious, however, that students' misperception appears to be unaltered by their direct experiences with psychiatric treatment. Similarly to first-year medical students, who ranked psychiatry the lowest of 4 specialty choices when asked about "degree to which patients are helped,"3 fourth-year medical students going into other fields rated "effectiveness of psychiatric treatments" as the third most negative factor for their decision not to enter psychiatry.4 Thus, many medical students continue to question the efficacy of psychiatric treatment despite their medical school experiences.

One effective method to correct this misperception may be better integration of primary care and mental health care. In a recent study, fourth-year medical students' perception of treatment for mental illness became more favorable when psychiatry was cotaught with internal medicine and presented as a central and integral part of a medical patient work up.8 By integrating primary care and mental health care to better treat patients and improve perceptions of psychiatry, students may have a more positive clerkship experience, which may also translate into more interest in the profession.

References
1.
Sierles  FSTaylor  MA Decline of US medical student career choice of psychiatry and what to do about it. Am J Psychiatry. 1995;1521416- 1426
2.
US Department of Health and Human Services, Mental Health: A Report of the Surgeon General—Executive Summary.  Rockville, Md US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health1999;
3.
Feifel  DMoutier  CYSwerdlow  NR Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry. 1999;1561397- 1402
4.
Lee  EKKaltreider  NCrouch  J Pilot study of current factors influencing the choice of psychiatry as a specialty. Am J Psychiatry. 1995;1521066- 1069
5.
Paiva  REAVu  NVVerhulst  SJ The effect of clinical experiences in medical school on specialty choice decisions. J Med Educ. 1982;57666- 674
6.
Stoudemire  A Quo vadis, psychiatry? Psychosomatics. 2000;41204- 209Article
7.
National Mental Health Advisory Council, Health care reform for americans with severe mental illnesses. Am J Psychiatry. 1993;1501450- 1452
8.
Coodin  SChisholm  F Teaching in a new key: effects of a co-taught seminar on medical students' attitudes toward schizophrenia. Psychiatry Rehabil J. 2001;24299- 302Article
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